Office of General Counsel



GOVERNOR’S JUDICIAL ADVISORY COMMISSION

APPLICATION FOR APPOINTMENT TO THE COURTS OF COMMON PLEAS

1. Name: State full name (include any former names used).

2. Position: Identify the County/Judicial District for which are you applying

3. Residential Address: List current address and length of time at that address. If less than one year, list prior address.

4. Business Address:

5. Birthplace: Year and City, State.

6. Familial Status: Identify your family status and all members of your immediate family.

7. Education: In reverse chronological order, list each law school, college, or any other institution of higher education attended. Indicate for each the dates of attendance, whether a degree was received, and the date each degree was received.

8. Employment Record: List, in reverse chronological order, all governmental agencies, business or professional corporations, companies, firms, or other enterprises, partnerships, institutions or organizations, non-profit or otherwise, with which you have been affiliated as an officer, director, partner, proprietor, or employee since graduation from college, whether or not you received payment for your services. Include the name and address of the employer and job title or description. For each employer listed, identify the reason for leaving employment. State whether you have ever been discharged from employment for any reason or have ever resigned after being informed that your employer intended to discharge you.

9. Military Service and Draft Status: Identify any service in the U.S. Military, including dates of service, branch of service, rank or rate, serial number (if different from social security number) and type of discharge received, and whether you have registered for selective service.

10. Honors and Awards: List any scholarships, fellowships, honorary degrees, academic or professional honors, honorary society memberships, military awards, and any other special recognition for outstanding service or achievement.

11. Bar Associations: List all bar associations or legal or judicial-related committees, selection panels or conferences of which you are or have been a member. Give the titles and dates of any offices which you have held in such groups.

12. Bar and Court Admission:

a. List the date(s) you were admitted to the bar of any state and any lapses in membership. Please explain the reason for any lapse in membership.

b. List all courts in which you have been admitted to practice, including dates of admission and any lapses in membership. Please explain the reason for any lapse in membership. Give the same information for administrative bodies that require special admission to practice.

13. Memberships:

a. List all professional, business, fraternal, scholarly, civic, charitable, or other organizations, other than those listed in response to Questions 11 or 12 to which you belong, or to which you have belonged, post-education. Provide dates of membership or participation and indicate any office you held. Include clubs, working groups, advisory or editorial boards, panels, committees, conferences, or publications.

b. The American Bar Association's Commentary to its Code of Judicial Conduct states that it is inappropriate for a judge to hold membership in any organization that invidiously discriminates on the basis of race, sex, or religion, or national origin. Indicate whether any of these organizations listed in response to 13a above currently discriminate or formerly discriminated on the basis of race, sex, religion or national origin either through formal membership requirements or the practical implementation of membership policies. If so, describe any action you have taken to change these policies and practices.

14. Published Writings and Public Statements:

a. List the titles, publishers, and dates of books, articles, reports, letters to the editor, editorial pieces, or other published material you have written or edited, including material published only on the Internet. Attach an electronic copy of all published material or supply links to where the material can be accessed.

b. Supply any testimony, official statements or other communications relating, in whole or in part, to matters of public policy or legal interpretation, that you have issued or provided or that others presented on your behalf to public bodies or public officials.

15. Judicial Office: State (chronologically) any judicial offices you have held, including positions as an administrative law judge, whether such position was elected or appointed, and a description of the jurisdiction of each such court.

a. Approximately how many cases have you presided over that have gone to verdict or judgment? ______

i. Of these, approximately what percent were:

jury trials? ___%; bench trials ___% [total 100%]

civil proceedings? ___%; criminal proceedings? ___% [total 100%]

b. Provide citations for all opinions, published and unpublished, you have written, including concurrences and dissents.

c. Provide a brief summary of, and citations for, all of your opinions where your decisions were reversed by a reviewing court or where your judgment was affirmed with significant criticism of your substantive or procedural rulings. If any of the opinions listed were not officially reported, provide copies of the opinions.

16. Recusal: If you are or have been a judge, identify the basis by which you have assessed the necessity or propriety of recusal (If your court employs an "automatic" recusal system by which you may be recused without your knowledge, please include a general description of that system.) Provide a list of any cases, motions or matters that have come before you in which a litigant or party has requested that you recuse yourself due to an asserted conflict of interest or in which you have recused yourself sua sponte. Identify each such case, and for each provide the following information:

a.       whether your recusal was requested by a motion or other suggestion by a litigant or a party to the proceeding or by any other person or interested party; or if you recused yourself sua sponte;

b.      a brief description of the asserted conflict of interest or other ground for recusal;

c.      the procedure you followed in determining whether or not to recuse yourself;

d.      your reason for recusing or declining to recuse yourself, including any action taken to remove the real, apparent or asserted conflict of interest or to cure any other ground for recusal.

17. Public Office, Political Activities and Affiliations:

a. List chronologically any public offices you have held, other than judicial offices, including the terms of service and whether such positions were elected or appointed. If appointed, please include the name of the individual who appointed you. Also, state chronologically any unsuccessful candidacies you have had for elective office or unsuccessful nominations for appointed office.

b. List all memberships and offices held in and services rendered, whether compensated or not, to any political party or election committee. If you have ever held a position or played a role in a political campaign, identify the particulars of the campaign, including the candidate, dates of the campaign, your title and responsibilities.

18. Legal Career: Answer each part separately.

a. Describe chronologically your law practice and legal experience after graduation from law school including:

i. whether you served as clerk to a judge, and if so, the name of the judge, the court and the dates of the period you were a clerk;

ii. whether you practiced alone, and if so, the addresses and dates;

iii. the dates, names and addresses of law firms or offices, companies or governmental agencies with which you have been affiliated, and the nature of your affiliation with each.

iv. whether you served as a mediator or arbitrator in alternative dispute resolution proceedings and, if so, a description of the 10 most significant matters with which you were involved in that capacity.

b. Describe:

i. the general character of your law practice and indicate by date when its character has changed over the years.

ii. your typical clients and the areas at each period of your legal career, if any, in which you have specialized.

c. Describe the percentage of your practice that has been in litigation and whether you appeared in court frequently, occasionally, or not at all. If the frequency of your appearances in court varied, describe such variance, providing dates.

i. Indicate the percentage of your practice in:

1. federal courts;

2. state courts of record;

3. other courts;

4. administrative agencies

ii. Indicate the percentage of your practice in:

1. civil proceedings;

2. criminal proceedings.

d. State the number of cases in courts of record, including cases before administrative law judges, you tried to verdict, judgment or final decision (rather than settled), indicating whether you were sole counsel, chief counsel, or associate counsel.

i. What percentage of these trials were:

1. jury;

2. non-jury.

19. Litigation: Describe the ten (10) most significant litigated matters which you personally handled, whether or not you were the attorney of record. Give the citations, if the cases were reported, and the docket number and date if unreported. Give a capsule summary of the substance of each case. Identify the party or parties whom you represented; describe in detail the nature of your participation in the litigation and the final disposition of the case. Also state as to each case:

a. the date of representation;

b. the name of the court and the name of the judge or judges before whom the case was litigated; and

c. the individual name, addresses, and telephone numbers of co-counsel and of principal counsel for each of the other parties.

20. Outside Commitments During Court Service: Is it your intention to discontinue your occupation, business, or profession and to withdraw from any participation in the management of any such business enterprise if you become a judge? If not, provide explanation.

21. Potential Conflicts of Interest:

a. Identify the family members or other persons, parties, categories of litigation, and financial arrangements that are likely to present potential conflicts-of-interest when you first assume the position to which you have been nominated. Explain how you would address any such conflict if it were to arise.

b. Explain how you will resolve any potential conflict of interest, including the procedure you will follow in determining these areas of concern.

22. Pro Bono Work: An ethical consideration under Canon 2 of the American Bar Association’s Code of Professional Responsibility calls for “every lawyer, regardless of professional prominence or professional workload, to find some time to participate in serving the disadvantaged.” Describe what you have done to fulfill these responsibilities, listing specific instances and the amount of time devoted to each.

23. Judicial Evaluations/Recommendations: Provide all bar associations or organizations from whom you have sought recommendations or rating for judicial positions. Include the rating provided and the date the rating was given.

GOVERNOR’S JUDICIAL ADVISORY COMMISSION

APPLICATION FOR APPOINTMENT TO THE COURTS OF COMMON PLEAS

CONFIDENTIAL

NAME:

HOME ADDRESS:

TELEPHONE NUMBER (both home and office):

EMAIL ADDRESS:

1. Educational Disciplinary Record: For any institution listed in Section 7 of the main application, please describe any disciplinary investigation, action or other proceeding in which you were alleged to have done any wrongdoing, disciplined for wrongdoing, etc. for academic reasons.

2. Bankruptcy and Tax Information: Information under this heading must be provided for yourself and your spouse.

a. Have you and your spouse filed and paid all taxes (federal, state and local) as of the date of your application? Indicate if you filed “married filing separately.”

b. Have you ever owed any back tax payments? If so, indicate if back taxes were paid and provide full details.

c. Has a tax lien or other collection procedure(s) ever been instituted against you or your spouse by federal, state, or local authorities? If so, provide full details.

d. Have you or your spouse ever been the subject of any audit, investigation, or inquiry for federal, state, or local taxes? If so, provide full details.

e. Have you or your spouse ever declared bankruptcy? If so, provide full details.

3. Past Investigations and Complaints:

a. State whether, to your knowledge, you or any organization of which you were or are an officer, director, or active participant at a relevant time has ever been under federal, state, or local investigation for a possible violation of any civil or criminal statute or administrative agency regulation. If so, provide full details.

b. Have you ever been the subject of a complaint to any court, administrative agency, bar association, disciplinary committee, or other professional group for a breach of ethics, unprofessional conduct or a violation of any rule of practice? If so, provide full details.

4. Party to Civil Legal or Administrative Proceedings: State whether you, or any business of which you are or were an officer at a relevant time, have ever been a party or otherwise involved as a party in any civil, legal or administrative proceedings. If so, describe in detail the nature of your participation in the litigation and the final disposition of the case. Include all proceedings in which you were a party in interest. If you are or were a party as part of a partnership, include only if you were involved in a personal, managerial, or supervisory capacity.

5. Prior Arrests: Have you ever been arrested for, charged with, or convicted of a crime, other than a minor traffic violation, that is reflected in a record available to the public? If so, provide the relevant dates of arrest, charge and disposition, and describe the particulars of the offense.

6. Outstanding Commonwealth Debt: Describe any outstanding payments owed to the Commonwealth, including taxes, traffic offenses or other civic citations.

7. Deferred Income/ Future Benefits: List the sources, amounts and dates of all anticipated receipts from deferred income arrangements, stock, options, uncompleted contracts and other future benefits which you expect to derive from previous business relationships, professional services, firm memberships, former employers, clients or customers. Describe the arrangements you have made to be compensated in the future for any financial or business interest.

8. Disclosure: Describe any unfavorable information that may affect your nomination.

*** Additional information, including a complete financial net worth statement may be required upon recommendation for nomination.

AFFIDAVIT

I, _______________________________________________, do swear that the information provided in this statement is, to the best of my knowledge, true and accurate.

_________________________ __________________________________

(DATE) (NAME)

__________________________________

(NOTARY)

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